A contemporary analysis of morbidity and outcomes in cytoreduction/hyperthermic intraperitoneal chemoperfusion

Our plain-English summary of A contemporary analysis of morbidity and outcomes in cytoreduction/hyperthermic intraperitoneal chemoperfusion, by M. Haslinger, V. Francescutti, K. Attwood, et al (Cancer Medicine, 2013).

The study

• Authors: M. Haslinger, V. Francescutti, K. Attwood, J.A. McCart, M. Fakih, J.M. Kane, J.J. Skitzki
• Journal: Cancer Medicine
• Published: 2013;2(3):334-42
• Cited by: 51 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

The risks and benefits of cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (CS/HIPEC) continue to be debated by the oncology community. A retrospective analysis of contemporary data (2003-2011) was performed to provide objective information regarding surgical morbidity, mortality, and survival for patients undergoing CS/HIPEC at a comprehensive cancer center. While procedure-associated morbidity was comparable to other major surgical oncology procedures, there was no operative or 30-day mortality and 60-day mortality was 2.7%. Increasing numbers of bowel resections were found to correlate to an increased incidence of deep surgical site infections (including abscess and enterocutaneous fistula) and need for reoperation which was in turn associated with a decreased overall survival (OS) and progression-free survival (PFS). Five-year OS rates varied by site of tumor origin and histology (disseminated peritoneal adenomucinosis [91.3%], Mesothelioma [80.8%], Appendiceal Adenocarcinoma [38.7%], and Colorectal Adenocarcinoma [38.2%]). With an acceptable morbidity and mortality rate, CS/HIPEC should be included as an effective treatment modality in the multidisciplinary care of select patients with peritoneal metastases.

In plain English

This was a retrospective review of 112 patients who had cytoreductive surgery combined with heated chemotherapy inside the abdomen (CS/HIPEC, using mitomycin C) at Roswell Park Cancer Institute in Buffalo, New York, between 2003 and 2011. Most had cancer that had spread from the colon, rectum or appendix. Eleven patients (9.8%) had peritoneal mesothelioma. The article does not discuss asbestos. No patient died during the operation or within 30 days, and 3 (2.7%) died within 60 days. The most common complication was superficial wound infection (15.2%). Deep infections such as leaks or abscesses occurred in 10.7%. More bowel resections were associated with deep infection and with reoperation, and both of those were associated with shorter survival. Across all patients, 35 died during follow-up, median survival was 63.2 months, and five-year survival was 55.2%. Five-year overall survival was 80.8% in the 11 mesothelioma patients and 38.2% for colorectal adenocarcinoma. The authors concluded the procedure can be performed safely with acceptable morbidity. They noted the study was retrospective, came from one center, and had no comparison group.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Retrospective review of one institution's surgical case series
• Who was studied: 112 patients who underwent CS/HIPEC at Roswell Park Cancer Institute, Buffalo, New York, from 2003 to 2011. Tumor types were colorectal adenocarcinoma 38, appendiceal adenocarcinoma 24, disseminated peritoneal adenomucinosis (DPAM) 27, peritoneal mesothelioma 11 (9.8%), and other 12. Median age was 53 and 59.8% were female.
• Exposure: Not an asbestos exposure study. The treatment studied was cytoreductive surgery followed by closed hyperthermic intraperitoneal chemotherapy at about 41 degrees for 60 to 120 minutes. Patients received 30 mg mitomycin C plus an additional 10 mg at 60 minutes; the dose was reduced in 25.9% of patients.
• Main results:
  • Among all 112 patients there were no operative or 30-day deaths, and 60-day mortality was 2.7% (3 patients).
  • Superficial surgical site infection occurred in 15.2% of patients (17) and deep surgical site infection in 10.7% (12).
  • A greater number of bowel resections was associated with deep surgical site infection (odds ratio 2.79, 95% CI 1.40 to 5.56, P = 0.004) and with reoperation (odds ratio 3.65, 95% CI 1.45 to 9.16, P = 0.006).
  • Across all patients, 35 deaths were observed. Median overall survival was 63.2 months, 5-year overall survival was 55.2%, and median progression-free survival was 22 months.
  • Five-year overall survival was 59.7% in patients without deep surgical site infection and 16.4% in those with one. Deep infection (P = 0.0001) and reoperation (P < 0.0005) were associated with worse overall survival.
  • Peritoneal mesothelioma patients (n = 11): 5-year overall survival 80.8%, median 68.5 months, hazard ratio 0.39 (95% CL 0.11, 1.36) compared with colorectal adenocarcinoma. Their 5-year progression-free survival was 70.7%, hazard ratio 0.21 (0.06, 0.70). Five-year overall survival was 38.2% for colorectal adenocarcinoma, 38.7% for appendiceal adenocarcinoma, and 91.3% for DPAM.
  • Excluding DPAM, complete cytoreduction showed a trend toward better overall survival that was not statistically significant (P = 0.0659).
• The authors' conclusion: The authors concluded that CS/HIPEC in the contemporary setting can be performed safely with minimal postoperative mortality and acceptable morbidity, and should be part of multidisciplinary care for select patients with peritoneal metastases. They suggested that patients needing multiple bowel resections may not benefit.
• Limitations the authors state:
  • Retrospective design; any selection bias would be hard to determine, and strict eligibility criteria may have improved survival figures.
  • No intraoperative Peritoneal Cancer Index scoring, which limits comparison with other series.
  • No comparison group of patients treated with systemic chemotherapy only.
  • Single-institution results may not apply to other treatment centers.

Topics

Medical terms in this study, explained in our Lexicon: Cytoreductive Surgery, HIPEC, Bowel Resection, Overall Survival, Progression-Free Survival, Histology, Mesothelioma, Adenocarcinoma.

Related studies

• Preoperative Thrombocytosis Predicts Shortened Survival in Patients with Malignant Peritoneal Mesothelioma Undergoing Operative Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy — Y.C. Li, T. Khashab, et al. (2017)
• The Role of Ki-67 and Pre-cytoreduction Parameters in Selecting Diffuse Malignant Peritoneal Mesothelioma (DMPM) Patients for Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) — S. Kusamura, P.A. Torres Mesa, et al. (2016)
• Outcomes of Cytoreductive Surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) in patients older than 70 years; survival benefit at considerable morbidity and mortality — K.I. Votanopoulos, N.A. Newman, et al. (2013)
• Early recurrence after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) — G.H.C. Tan, C.S. Chia, et al. (2018)
• Multicystic peritoneal mesothelioma: outcomes and patho-biological features in a multi-institutional series treated by cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) — D. Baratti, M. Vaira, et al. (2010)
• Iterative cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for recurrent or progressive diffuse malignant peritoneal mesothelioma: clinicopathologic characteristics and survival outcome — C. Ihemelandu, L. Bijelic, et al. (2015)

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